Funds Proctor

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following action should the nurse take first? A.) Eval pedal pulses B.) Obtain medical hx C.) Measure v/s D.) Assess for leg pain

A.) Eval pedal pulses

A nurse is caring for a client who has injuries resulting from a motor-vehicle crash. Which of the following client statements should the nurse address first? A.) "I'm afraid this injury will cause me to lose my job." B.) "I can't sleep well because whenever I move in my sleep, the pain wakes me up." C.) "Idk what I will do if my car isn't safe or even drivable after the crash." D.) "I wonder how I am going to be able to take care of my fam"

B.) "I can't sleep well because whenever I move in my sleep, the pain wakes me up."

A nurse is providing teaching about crutches to a client who has a fracture of the right foot. Which of the following instructions should the nurse include? A.) "When u go up a flight of stairs, place ur right foot on the first step." B.) "Keep the rubber crutch tips securely in place" C.) "When standing, keep the crutches 12inches in front of u & 12inches to the side." D.) "Place ur WT on the crutch pads @ ur armpits"

B.) "Keep the rubber crutch tips securely in place"

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? A.) Redness @ infusion site B.) Edema @ infusion site C.) Warmth @ the infusion site D.) Oozing of blood @ infusion site

B.) Edema @ infusion site

A nurse is caring for a toddler @ a well-child visit when the mother calls, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction? A.) Flushing of the skin B.) Inability to cry or speak C.) Presence of nausea & mild emesis D.) Capillary refill time of 1.5 sec

B.) Inability to cry or speak

A nurse is assessing a client who has a sudden onset of severe back pain on unknown origin. Which of the following questions should the nurse ask to encourage discussion w/ the pt? A.) "Does the med you've been taking relieve the pain?" B.) "Can you point to where the pain is the worst?" C.) "What do u think caused the onset of ur pain?" D.) "Changing positions makes ur pain worse, right?"

C.) "What do u think caused the onset of ur pain?"

A nurse is caring for a client who requires ventilatory assistance w/ breathing following a motor vehicle crash. The nurse should suspect an injury to which of the following parts of the brain? A.) Hypothalamus B.) Cerebral cortex C.) Brainstem D.) Cerebellum

C.) Brainstem

A nurse is assisting a client who is eating @ a mealtime. Suddenly, the client grabs her neck w/ both hands & appears frightened. Which of the following actions should the nurse take first? A.) Place an O2 mask on the pt B.) Check the pt's pulse C.) Determine whether the pt is able to breathe D.) Wrap arms around the Pt from behind

C.) Determine whether the pt is able to breathe

A nurse is assessing a client who is unconscious. Fam members are present & answer the nurses's ?s about the client's med hx. The nurse should document this info as which of the following types of data? A.) Secondary-source data B.) Experiential data C.) Primary-source data D.) Quantitative data

C.) Primary-source data

A nurse in the ER is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? A.) Warm, dry skin B.) Increased urinary output C.) Tachycardia D.) Bradypnea

C.) Tachycardia

A nurse is preparing to irrigate the client's wound? Which of the following actions should the nurse take? A.) Use a 10mL syringe B.) Attach a 22-gauge catheter to the syringe C.) Warm the irrigating sol to 37 C (98.8 F) D.) Admin an analgesic 10min before the irrigation

C.) Warm the irrigating sol to 37 C (98.8 F)

A nurse is caring for a client who is unstable & has V/S q15mins by an electronic BP machine. The nurse notices the machine begins to measure the BP @ varied intervals & the readings are inconsistent. Which of the following actions should the nurse take? A.) Turn on the machine q15mins to ensure the client's BP B.) Record only the BP readings needed for 15min intervals C.) Obtain manual & automatic readings & compare them D.) Disconnect the machine & measure the BP manually q15mins

D.) Disconnect the machine & measure the BP manually q15mins

imminent

about to happen

A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health-associated infections (HAIs). Which of the following should the nurse identify as an iatrogenic HAI? A.) Infection acquired from improper hand hygiene B.) Infection caused by drug resistance C.) Infection acquired by inappropriate waste disposal D.) Infection acquired from a diagnostic procedure

D.) Infection acquired from a diagnostic procedure

A nurse is preparing to admin an afternoon dose of ampicillin to a client. The client appears upset & refuses to take the med before throwing the pill on the floor. Which of the following entries should the nurse enter into the client's med record? A.) The client refused to take the med today B.) The client stated, "I will not take this pill." C.) The client seemed angry & hostile D.) The client threw the med on the floor

D.) The client threw the med on the floor

A nurse is witnessing a client sign an informed consent form for surgery. What is the nurse affirming by this action? A.) The client fully understands the provider's explanation of the procedure B.) The client has been informed about the risks & benefits of the procedure C.) The nurse witnessed the provider's explanation of the procedure D.) The signature on the pre-op consent form is the client's

D.) The signature on the pre-op consent form is the client's

A nurse is obtaining a capillary blood sample to determine a client's BG level. The nurse prepares & punctures the client's finger for the procedure but DOESN'T obtain an adequate amount of blood. Which of the following actions should the nurse take next? A.) Smear the SM amount of blood onto the testing strip B.) Hold the finger about heart level C.) Massage the client's fingertip D.) Wrap the client's finger in a warm washcloth

D.) Wrap the client's finger in a warm washcloth

iatrogenic

produced by treatment